Nexium — Cigna
Acid-related diseases such as duodenal and gastric ulcerations, gastroesophageal reflux disease, Zollinger-Ellison syndrome, and Helicobacter pylori infections
Preferred products
- generic esomeprazole delayed-release capsules
- generic lansoprazole delayed-release capsules
- generic omeprazole delayed-release capsules
- generic omeprazole delayed-release tablets
- generic pantoprazole delayed-release tablets
- generic rabeprazole delayed-release tablets
Initial criteria
- If the patient is age < 1 year, approve generic esomeprazole delayed-release granules for oral suspension (packets) OR Prilosec delayed-release granules for oral suspension (packets).
- If the patient is age < 11 years AND requires administration via a feeding tube, approve generic esomeprazole delayed-release granules for oral suspension (packets) OR Prilosec delayed-release granules for oral suspension (packets).
- If the patient requires administration via a feeding tube AND has tried a Step 1 Product under the supervision of a physician, approve a Step 2 Product EXCEPT Konvomep, Zegerid, Zegerid OTC, AND generic omeprazole/sodium bicarbonate capsules (Rx and OTC). Note: A trial of a generic OTC proton pump inhibitor qualifies.
- If the patient has tried a Step 1 Product under the supervision of a physician, approve a Step 2 Product EXCEPT Konvomep, Zegerid, Zegerid OTC, AND generic omeprazole/sodium bicarbonate capsules (Rx and OTC). Note: A trial of a generic OTC PPI qualifies if OTC PPIs are a covered benefit and used ≥ 14 days.
- If the requested product is Konvomep, Zegerid, Zegerid OTC, or generic omeprazole/sodium bicarbonate capsules (Rx or OTC), approve if the patient has tried five generic proton pump inhibitors (esomeprazole [Rx and OTC], lansoprazole [Rx or OTC], omeprazole [Rx or OTC], pantoprazole, and rabeprazole). Note: A trial of a generic OTC PPI qualifies if OTC PPIs are a covered benefit and used ≥ 14 days.
Approval duration
1 year